Hardware, software, people, policy, and process must work together to achieve your organization's EHR goals. One of the earliest matters that policy must address surrounds organizational readiness for an EHR. In fact, having a policy of regular readiness assessment is an important step toward success. Even if a certain project with a certain group goes smoothly, that doesn't guarantee success for another project. You may think a policy that focuses attention on planning is not necessary, but implementing an EHR is a spiral of change, with each cycle repeating itself in many ways, often with new twists and turns.
Somewhere between the third urgent item on your to-do list, getting your budgets prepared, and responding to the latest auditor's requests lies the omnipresent responsibility of nurturing the validity of the medical record. HIM professionals have traditionally been the legal custodians of the record. (After all, who else is daring enough to testify in court on the accuracy of the EHR?) Have we also by default become the custodians of data integrity?
Editor's note: As part of our yearlong celebration of MRB's 25th year, we wanted to take a look back at article excerpts from years past. In some ways, things haven't changed much-getting physicians to complete documentation in a timely manner is still a challenge-but in others, it is clear that HIM has come a long way.
If you are gearing up for a computerized provider order entry (CPOE) implementation, there are some tips and tricks that will help you stay on top of the transition.
I promised in a previous “Standards of the month”column that I would address Joint Commission standard MM.04.01.01 (orders for medication are clear and accurate), as this standard made it onto the 2010 top 10 list of standards with which hospitals were noncompliant. In fact, 30% of hospitals failed to comply with it.
After 10 years, the requirements for signatures on lab requisitions are still in flux; CMS published the latest change to the lab signature requirements in the 2011 Medicare Physician Fee Schedule (MPFS) final rule published in the Federal Register November 29, 2010.
